Provider Demographics
NPI:1972710226
Name:VAN WELL, PETER H (PT)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:H
Last Name:VAN WELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9664 HEMINGWAY
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2203
Mailing Address - Country:US
Mailing Address - Phone:313-937-0856
Mailing Address - Fax:
Practice Address - Street 1:5500 AUTO CLUB DR STE 150
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2779
Practice Address - Country:US
Practice Address - Phone:313-982-8266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010062722251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic